Change of Address Form

Please complete this form to advise us of your change of address or any other changes to your contact details. Before completing this form, you need to check that your new address is still within our catchment area. If you have moved outside our catchment area, you will need to register with a local GP. To find a GP practice in your area use the NHS Choices website.

1 Previous Details

Full NameIncluding Title

Can you provide your Previous NHS or Patient Number?This will allow us to locate you quickly on our Patient Database.

NHS Number

2 Previous Address

Previous Address

Previous Postcode

3 Previous Contact Details

E-mail Address

Home Phone Number

Mobile Phone Number

4 New Details

Provide details where different to previous.

Full NameIncluding Title

Date of BirthPlease provide in the format dd/mm/yyyy

Can you provide your New NHS or Patient Number?This will allow us to locate you quickly on our Patient Database.

Family Member 5

9 Hospital Referrals

10 Privacy

I agree that the surgery may contact me by e-mail or telephone to discuss the information contained in this form.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key known only to the GP practice and is
accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form toThe Abingdon Medical Practice
•
88-92 Earls Court Road, Kensington, London, W8 6EG.

Learn more about our Privacy Policy and
Terms of Use.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.